Pesticide Dealer License

APPLICATION FOR PESTICIDE DEALER LICENSE
Section 487.046(1), F.S., and Rule 5E-9.026 F.A.C.

Applicant must be 18 years of age or older to apply. Provide the details below. Fields marked with red asterisk are required. (Date Format: mm/dd/yyyy, Phone Format: 999-999-9999)

Applicant Information

Name of Company or Individual Requesting License: * Required	Email: * Required Format: ex@email.com

Business Phone:

Cell Phone:

Home Phone:

Fax Number:

Applicant Address
Business Address: * Required	Line 2:	Business City: * Required	State: * Required	Zip Code: * Required

Mailing (if different):	Line 2:	Mailing City:	State:	Zip Code:

Home Address:	Line 2:	Home City:	State:	Zip Code:

Authorized Agent Information
First Name: * Required	Middle Name:	Last Name: * Required

Date of Birth: * Required Format: mm/dd/yyyy	Title:

WILTON SIMPSON, Commissioner